movement expert

So, when does physical therapy end?

This is just a short piece, a reflective piece, about a value that makes up the very core of what I believe in and what I strive to achieve as a Physiotherapist – empowering my patients with the knowledge and the skills they need to make themselves independent.

These past few weeks have reminded me of a very special part of treating patients – discharging them. For months now I have worked intensely to help the small patient population with whom I have contact. After investing so much time in their development and progress, it is a magical moment when they come to me and say “I am not 100% better but I know what the problem is and I know how to make it better. What I need now is time to follow through on my goals and I can take it from here.”

What a pleasure it is to hear that. I know no one will ever be 100% when it comes to discharge and I am fine with that. First, I don’t set “being 100% pain free” as a goal and secondly, I think we all suffer from pain at some point in time. What I feel is more important is for patients to function normally and in the most ideal way for their lives.

Something patients frequently ask is “How long do I need to keep coming to Physical Therapy?” Or, “Will I always need to do these exercises?”

The answer to the first – how long does it take you to no longer need Physical Therapy?

The answer to the second – No, you will need them when you need them.

What do I mean by this? Let’s take a look at the ideal stages of recovery involved between initial assessment and discharge.

STEP 1 – LET ME HELP STEER YOU IN THE RIGHT DIRECTION

It all starts at the beginning, when life is altered by pain or injury and when patients seek care because they don’t function in their normal way anymore. Sometimes it can be tough to get the ball rolling, to retrain movement patterns and daily habits, to get pain levels under control, and to motivate patients to begin to drive their own recovery. The first step as Physical Therapist is to understand the problem, the contributing factors, to identify milestones that help patients identify with their own recovery process, and then begin guiding them through rehab until they reach step 2.

STEP 2 – START TO TAKE THE WHEELS

Once pain is no longer driving a willingness to come to therapy, what is?

As I often say to my patients – I will sit beside you on this journey to recovery, but I will not drive you there. So, Step 2 is all about helping patients recognise what other barriers need to be overcome or goals need to be achieved before they can function unrestricted.

STEP 3 – NOW IT’S YOUR TURN TO DRIVE

Once you are functioning well, do you know how to stay that way?

At this point in time I hope that my patients are developing a sound knowledge about how their bodies present/move/behave when they are both feeling good and feeling not so good. Developing this self awareness is a key step towards understanding their bodies better and identifying how their rehab should progress for them to be 100%.

STEP 4 – I AM NO LONGER A PASSENGER

If you’re staying symptom free and doing what you love – do you still need my help?

It is definitely sad to say goodbye but we have to set our patients free. This past week has been sprinkled with discharge assessments–patients who come in smiling because they only have good news to report. They are playing the sports they love, can use exercises to manage any niggles that may come up, are no longer thinking about their injury or their body part, and can see the end goal in sight. And this is when I ask – do you still need my help to get to the end? And with a smile, they reply, “I can take it from here”.

If you are reading this as a patient I want to to ask yourself:

Are you self-discharging too soon? There is a lot of work that lies between reducing pain and discharge.

Are you holding on too long?

Are you taking the steps along the entire journey to make sure your knowledge is developing and growing to accommodate for the changes in your body at that given time?

At TherapydiaSF we strive to form strong relationships with our patients. Communication is the key to break down what problems exist and create individualised treatments for those problems. We all have our niche areas or injuries we love treating, but at the end of the day, you are the person that will direct the treatment path and we are here to help and facilitate you to reach those goals.

Sian Smale, PT, MPhysio has been part of the TherapydiaSF team since 2016. Originally from Australia, Sian is trained in Musculoskeletal Physiotherapy and Clinical Pilates. When not working as a physiotherapist, you can find Sian cycling the hills of Marin, swimming in the elusive outdoor pools of the Bay Area, and chasing down the best avocado toast.

It’s a new year and, for many people, this means a new insurance policy. While insurance can be confusing, it is important to understand your health insurance benefits as you consider your options for treatment. We’ve put together a handy primer to explain the basic components of an insurance plan, in hopes that it will make life simpler for you!

In-Network vs. Out-of-Network: Providers who are in-network with your insurance company have agreed to accept a lower rate for their services, as determined by the insurance company, in exchange for being affiliated with and promoted as a “preferred provider”. Out-of-network providers determine the value of their services and are not under contract with the insurance company. Most plans have some level of out-of-network reimbursement. Many people think that if a practice is not in-network with their insurance, they can’t seek services at that clinic. In fact, insurance companies may even tell you you have to work with an in-network provider, even if you have out-of-network coverage. This is wrong and misleading. We elaborate more on the difference between in- and out-of-network coverage in this past blog.

Explanation of Benefits (EOB): This is sent by mail or available online after each medical service you receive. Your EOB will include lots of information, but look for the billed amount, allowed amount, any payments made by your insurance company, and the amount you owe, or patient responsibility.

Allowed Amount: The amount your insurance company deems a service provided to you is worth. This may be equal to the billed amount, though is more often less than the billed amount.

Deductible: This is the amount of money you are required to pay before your insurance benefits kick in. This amount resets annually, typically at the beginning of the year. Occasionally, there are some services where the deductible is waived, but in general you are required to pay the amount of your deductible before insurance pays for anything. Generally, there are separate deductibles for in- and out-of-network providers, though occasionally they are combined.

Coinsurance: Generally, this is the percentage of what you are required to pay per service. This is most often calculated using the allowed amount. For example, 30% coinsurance means that you are required to pay 30% of what your insurance allows for a particular service, while they pay 70%. This shared payment responsibility starts only after you meet your deductible.

Copay: This is a flat-rate amount that you pay each time you visit a provider, regardless of the billed or allowed amounts. This won’t start until you have met your deductible.

Out-of-pocket max: This is the maximum amount of money you will have to pay per year for covered healthcare. Once you reach your out-of-pocket max, insurance should cover 100% of your medical expenses.

Visit limit: This is the maximum number of visits your insurance company will pay. However, this is not a guarantee. Often, an insurance company will state a high number, or even unlimited visits, but will deny payment after review of medical notes if they don’t consider treatment to be justified.

At TherapydiaSF, we are happy to call your insurance on your behalf to determine your specific in- or out-of-network benefits. We also offer discounted cash rates as an alternative, if you are faced with a high-deductible plan, high co-insurance or limited visits. Please let us know how we can help you get started on your path to a healthy 2017!

Marathon training has picked up and your Achilles tendon has been bothering you on your long runs. Or maybe you played golf this weekend and your back has been sore ever since. Perhaps work has gotten busy and your neck has been sore for a week. Whether it’s a friend or your doctor, chances are, if you ask around, someone will suggest you see a physical therapist.

So what should you expect?

During your first visit your PT will work to understand your injury and develop a treatment plan. We will ask you questions about your pain or discomfort—when did it start, what makes it better, what makes it worse? We will ask you about your work and the things that you do for fun. Sure, we want to get to know you, but, more importantly, that info also helps us understand how to best help you and keep you as active as possible while you’re recovering.

We will watch you do certain movements and collect some information by taking measurements and conducting particular tests. Often we will even look at different areas of your body that may not seem to be related to your injury.

Once we feel like we have enough information to create your treatment plan, we will likely get started that first day by teaching you an exercise or two to work on until your next appointment.

You should expect to work with the same PT at each session. Occasionally, two PT’s will work together as a team during your course of treatment, but our goal is to maintain consistency from visit to visit, and we find this harder to accomplish when more than two PT’s are involved.

When you return for your first follow up visit, expect to get to work! Your PT will have developed a plan that may include a variety of manual therapy techniques (‘hands-on’ work) and will definitely include exercise. We might ask you to do some things that seem silly—feel free to ask us why. It is not uncommon to see our patients blowing up balloons during their appointments, or crawling across the gym mat. It’s actually fun and we laugh a lot! At each session we will check and recheck some of the same tests we performed on day one, to understand the effect of the treatments we have been providing.

When you leave our studio, you will be expected to do your homework. We will provide resources to help you remember your exercises and yes, we will know if you’re doing them. Patients who are active participants outside of the PT clinic almost always heal faster than those who aren’t. A physical therapist can’t make you better alone. Physical therapy is a team approach and we need your help!

How often you come to PT is part of the treatment plan that you and your therapist develop together. Among our patients, there is a wide range of plans that change over time (i.e. once per week, once every other week, twice per week, etc). There are several factors we consider when planning your PT schedule. From the rate of healing and the body’s adaptation to new activities, to being swamped at work or due to financial constraints, treatment schedules will be specifically recommended to fit your needs. However, you should expect to attend at least 3-5 sessions in order to get the full benefit of working with your PT.

Once you are back to your marathon training, out on the golf course, or are able to sit at your computer without neck pain, it’s probably time to graduate from physical therapy! Some of our patients choose to continue to work with their PT for exercise as part of one of our wellness programs while others reach out the next time they need us.

I’d like to take a moment introduce myself as I am so grateful to be the newest member of the TherapydiaSF family. My name is Michelle Cotter and I’m a physical therapist. While I specialize in pediatrics, I love treating adults as well.

My passion for helping people heal began as a youngster when I volunteered in the athletic training room at my high school while rehabilitating my own injuries. It was further strengthened when I spent the summer of my junior year in high school helping my mom recover from heart surgery. I received my Doctorate in Physical Therapy from Samuel Merritt University in Oakland, California and completed my final internship at Lucile Packard Children’s Hospital, where I learned the intricacies of proving excellent patient care to children and their families. My experience working on the UC Davis Athletic Training team, as well as over 5 years of clinical experience, has helped me develop expertise in identifying movement dysfunction and choosing the best treatment methods for a variety of injuries for all ages.

Over the past 3 years, I have also been treating infants and children, assisting in their gross motor development, so that they are able to play and participate in age-appropriate activities with their peers. I have had particular success in developing effective rehabilitation programs for children with developmental delay, positional plagiocephaly and a variety of sports-related injuries.

My goal as a physical therapist is to provide an individualized framework for healing based on current research and patient education. I aim to facilitate the recovery and prevention of injuries for each patient, no matter what age, so that they may achieve their mobility goals.

I love educating patients about how their body moves and teaching them strategies to change dysfunctional movement patterns. I emphasize educating patients and families on their specific condition and how they will take an active role in the recovery process for optimal health and function. This approach to an interactive plan motivates me to be the best physical therapist I can be. I get great satisfaction in building collaborative partnerships focused on the achievement of life-long health and wellness with my patients

I am very excited for the opportunity to work in such a collaborative and interactive environment that promotes long-term health and wellness and I look forward to meeting each of you! Please feel free to contact me if you would like more information.

I sat down earlier this week to write a piece with the title above, but very quickly realized there really aren’t that many reasons. The only reason we are out-of-network with most insurance plans comes down to one simple fact:

We want to offer physical therapy treatment on our own terms, the way physical therapy was intended to be provided.

Most plans have out-of-network reimbursement. Many people think that if a practice is not in-network with their insurance, they can’t seek services at that clinic. The truth is, in most cases, you can work with a PT who is out-of-network. All it means to be in-network is that a physical therapy provider has signed a contract with a health insurance company that allows the insurance company to decide on the value of the physical therapy provided. Sadly, the current climate of physical therapy insurance reimbursement often has providers being paid less than the cost of a personal training or Pilates session, haircut, or full tank of gas.

All physical therapy is not created equal. PT’s do not receive a handbook on graduation day that tells us how to treat a specific diagnosis. Treatment should be customized, taking into consideration an individual’s activities, lifestyle, home and work demands, and even emotions related to the injury or pain.

All physical therapists are not created equal. Some PT’s further their education by taking classes and additional training beyond what is required by our governing board. Some PT’s look for every opportunity to expand their knowledge and stay current with studies and treatments. Good PT’s know that there is not one treatment to help everyone and, while we may not be able to cure all, we have a network of additional resources who might.

All components of physical therapy, from hands-on treatment to exercise, should be delivered by physical therapists.

We have chosen to stay true to our ideas of how physical therapy should be delivered. We find that our 45-minute treatment sessions, spent entirely with a physical therapist, help us form relationships with our patients, allow us to address multiple components of pain and injury, and often expedite treatment.

While out-of-network benefits vary, we have discovered that out-of-network reimbursement is often comparable to in-network coverage.

What does this mean for you?

We will:

provide excellent customer service from the first call.

check your benefits and discuss these with you before your first visit so that you have an understanding of the payment and reimbursement process.

help you find the best PT fit.

follow up with your insurance company on outstanding reimbursements.

reimburse you as soon as we receive payment from your insurance company.

What’s different?

Your PT may structure a different plan of care than used in traditional PT. Do you really need 2 times per week for 8 weeks? Maybe not. Your PT will work with you to develop a plan that will help you recover effectively, while keeping in mind schedule and financial concerns.

We expect you to be actively involved in your own recovery. We can’t make you better by ourselves.

You will have homework. We may ask you to modify some of your activities (Thought you knew how to sit?? Think again). We make these recommendations not to put a wrench in your lifestyle, but because we know they will help expedite the healing process.

We will be available to encourage and support you along the way.

You can access your PT via email in between appointments if you have questions or concerns.

Please let us know if we can help you learn more about your physical therapy benefits. We will gladly call your insurance to verify your coverage and provide you with the information we receive. We look forward to helping you on your path to recovery!

Let’s face it. Most physical therapists aren’t winning any sales and marketing awards. Most of us have don’t have a business background and typically enter this profession based on a love of health, exercise and helping others. In school, we don’t really have time to cover anything beyond examination and treatment of our soon-to-be patients. We graduate, enter the world of health and wellness as practitioners of physical therapy, and soon realize the competition is fierce. In San Francisco, a city with something for everyone, there are individuals providing health and wellness services that seem in direct competition with everything we offer. There are personal trainers, massage therapists, Muscle Activation Therapists, Sports Therapists, Neurokinetic Therapists, Core Activation Therapists, and more. Have you ever stopped to consider who is best trained to help you heal? While these practitioners may indeed be skilled at the services they offer, based on our level of education and training, physical therapists are in a league of our own.

The other day, I had a pleasant conversation with a gentleman who was interested in learning more about the field of physical therapy. A seemingly intelligent man, he’d also had personal experience as a recent physical therapy patient. At some point in our conversation, he stopped me and asked, “Do you have to have some sort of certificate to be a physical therapist?” My jaw dropped. It was then and there I realized how physical therapists have done such a terrible job of informing the public of what we do, what we can offer, and why we should be considered the practitioners of choice for musculoskeletal health.

So here’s what you should know: physical therapists go to school for 7-8 years. This includes 4 years of undergraduate education, heavily based in science (physics, chemistry, microbiology, exercise physiology, etc.), and 3-4 years of graduate-level education. Students graduating from physical therapy programs in the United States today earn a Doctor of Physical Therapy. The first Doctorate program in Physical Therapy was started in 1993 at Creighton University in Nebraska and, as of 2015, all accredited and developing physical therapist programs are DPT programs. Often part of a medical school, PT programs teach physical therapy examination and treatment, as well as courses in Anatomy, Neuroanatomy, Pathology, Pharmacology, Radiology and Differential Diagnosis (how I determine if a symptom may be something more serious—and outside of my scope of practice—than run-of-the-mill back pain). In fact, when I attended UCSF in the early 2000’s, the physical therapy students were the only students who performed full cadaveric dissections. Other programs used the cadavers we spent our first foggy summer in San Francisco dissecting. It was also the start of our collaboration with the first year medical students, where we 2nd year PT students helped teach the medical students musculoskeletal anatomy. Most recently, residencies and fellowships after graduation have grown in popularity to provide advanced training for physical therapy school graduates.

Beyond our formal education, physical therapists are licensed by the state in which we practice and are held to a high level of professional conduct that includes requirements for continuing education every year. Most courses are held on the weekends and many physical therapists travel great distances to take courses of interest. This year alone, PT’s from TherapydiaSF will take courses in San Francisco, San Diego, Montana, and Las Vegas. Some physical therapists also opt to enhance their degree and training by completing board certification in different areas of practice, including Orthopaedics, Pediatrics, Women’s Health, Neurology and 4 other areas of specialty practice.

The next time someone suggests physical therapy, please consider our extensive training and education and know that we have the education, expertise and dedication to help you work, play and move without pain.

Many of the patients I treat are extremely active, though few make their living playing sports professionally. They are passionate about their lifestyle and sport of choice, and take their health very seriously. With many sports and hobbies, aches and pains are likely to occur. Athletes quickly get used to sore muscles and minor injuries, often considering these a normal part of an active lifestyle.

But should these be treated more seriously?

Many of the patients with whom I work initially ignored what seemed to them to be minor injuries, yet have since become more frequent or more intense.

At what point should you visit a physical therapist?

Read more for quick tips to decide if what you’re feeling needs a closer look.

1.Immediately after a specific injury.

A number of recent studies have shown support for early physical therapy for lower back pain. The studies show that physical therapy within 2-4 weeks of a lower back injury leads to a decreased risk of surgery and injections, fewer doctor visits, faster recovery, and fewer incidents of chronic pain.

Clinically, I have seen even earlier physical therapy provide excellent results. I am a strong advocate of patients developing a relationship with a physical therapist as a practitioner on their medical team (see post). I also believe that patients should have email access to their physical therapists in order to communicate updates and ask general questions. Often, a patient will email or call our office within the first few days of an injury and we will schedule them that day. Earlier this year, I worked with a triathlete who developed intense back pain after a weekend race. We saw her the next day and within a week she reported an 80% decrease in her symptoms. The following week she reported a 95% improvement and was able to race again exactly one month later. The sooner we can see a patient post-injury, the faster their recovery from the painful, acute stage. This allows us to move to more advanced stages of physical therapy earlier, in order to address the root cause of their injury.

2.If an old injury has reappeared or never disappeared!

As I was getting ready to graduate one of my runners from physical therapy the other day, she asked, “but…how will I know if I need to come back?” It was a great question, yet one without a definitive answer. Runners, especially, are subject to occasional minor aches and pains. At what point should they take these more seriously and seek help?

In general, you should reconnect with your physical therapist when:

You feel pain during an activity that gets worse as you continue the activity. This is a sign that something is not right.

Your pain changes the way you perform the activity. If you are running down the street with foot pain and you have to limp so it doesn’t hurt as much, go home and call your PT. Remember, the faster the painful symptoms are addressed, the more likely the root cause will be identified and other related injuries are less likely to occur.

You feel pain during three consecutive workouts or activities. Often pain will be present at the start of an activity, but will disappear within a few minutes. Does that mean it should be ignored? No. If you are consistently feeling the same or similar symptoms, even if they go away during the activity, schedule an appointment. Pain is a sign of tissue fatigue or too much stress on a particular part of the body, likely related to an underlying movement dysfunction. In English? You’re likely not moving as well as you could, an area of your body is doing more than its fair share of the work, and it needs some help.

3.For an annual check up.

Physical therapists can be, and should be, the medical practitioners of choice for a musculoskeletal wellness/fitness screen, an assessment with a physical therapist to identify risk factors for developing a particular injury. Much like we visit the dentist on a regular basis, we believe that everyone should schedule an annual preventative visit to their physical therapist to identify and address areas of dysfunction (that tight neck you’ve been complaining about, poor posture, or the shoulder that occasionally hurts in your bootcamp class). Left undetected, these will likely get worse over time. We would much rather see you once a year to revise your exercise program and keep you healthy, than have you wind up in our office as our newest patient!

Remember, you shouldn’t try to tough it out or wait until an injury becomes more severe before visiting your physical therapist. You will wind up suffering needlessly and make our jobs even harder!

If you’re still not sure you should come in for an assessment, feel free to email us: hello@therapydiasf.com.

In your email, please provide the following:

-where is the location of pain?

-how did the injury occur?

-how long have you had the pain?

-what makes it hurt?

-what makes it feel better?

We will review the information and advise you on the best option for your injury. This may include advice for self-management, the need to schedule a physical therapy assessment, or a physician contact, if necessary.

We are excited to welcome Lindsay Haas to the TherapydiaSF team! Sydney and Lindsay worked together several years ago when Lindsay was in her last year of physical therapy school at UCSF/SFSU. Since earning her DPT, Lindsay has practiced physical therapy in San Francisco, gaining quite the following of loyal clients! We are happy that she will now be working with us at TherapydiaSF. Lindsay joins the team this Monday, June 2 and will be treating patients daily, from 9:30-6:30.

A little more about Lindsay in her own words:

“The foundation of my practice as a physical therapist comes from my certification as an Orthopedic Clinical Specialist, and my ten years combined experience working as a PT in San Francisco and as a trainer for Division I college athletes at UCLA. My background in sports medicine and therapeutic exercise helps ensure my clients return to activity as soon as possible, and my knowledge in and passion for biomechanics – for which I use manual therapy techniques and neuromuscular re-education – helps them avoid future injuries.

By the end of physical therapy, I believe my clients should be experts on their own conditions and body. Through working together, my goal is that they learn the root causes of their ailments, as well as gain the tools they need to play a proactive role in their own long-term wellness. Being attentive and open-minded, I aim to listen to my clients’ words and bodies to create a rehabilitation and wellness plan that is catered to their goals. I love building long-term friendships with my clients, engaging personally with them in support of both their injury recovery and their long-term wellness.

My desire to continue learning and improve my practice motivates me to seek out and absorb the latest research and continuing education opportunities. My passion includes stopping injuries before they start, and I would like to see physical therapy grow to be not just about rehabilitation but also about injury prevention. As our profession evolves, I get excited about using all the great tools available combined with ongoing education to ensure my clients remain active in the pursuits they love.”

This post has been a long time coming, and I’m not particularly sure why. Perhaps I was worried I might ruffle some feathers, but when I read the recent editorial by Jas Randhawa, DC and DPT student Kyle Balzer, I was ready to write. PT’s in California are facing a fight in Sacramento that threatens to take away our ability to perform techniques that we have been practicing for years. SB 381 would prohibit physical therapists in California from performing joint manipulation, reserving the right to this technique to licensed chiropractors, physician/surgeons or osteopathic physician/surgeons. I don’t know about you, but I don’t know many physicians trained to do joint manipulation. However, HVLAT techniques are a part of physical therapy school curriculum. See this editorial for more on the history and training of the two professions:

But…I digress. The intent of this post isn’t to discuss SB 381, it is to share a lesson I’ve learned over the past couple of years.

The interaction between chiropractors and physical therapists has often been contentious, but over the past several years, I’ve asked myself if it really needs to be that way. PT’s and Chiropractors (we may as well throw Athletic Trainers into the mix) get so hung up on territory and competition and scope of practice, but the way I see it, it’s not only a waste of time and energy but leads to many missed opportunities for learning.

Some of my closest friends in the rehab world are not PT’s. Some of the people I respect most as clinicians in the rehab world are not PT’s. Some of my mentors are not PT’s. The one thing we have in common is that we’re not afraid to learn from practitioners outside of our discipline. As a result, I’ve been exposed to continuing education courses, have learned techniques that fall outside of the world of traditional PT courses and have become a better clinician because of it. I’ve been fortunate to have conversations with other rehab specialists, been able to discuss complicated cases approached from different perspectives and am a better clinician because of that.

Rather than staking claim to certain techniques or being worried that someone will take business away, we should spend our time and energy learning from one another to improve the health and optimize the function of our patients. Let’s face it, there will always be plenty of people who need our help.